Domestic Violence Human Trafficking

Section 4: High Risk Lethality of Abuser Women are often trapped in a dangerous and terrifying situation. Their partners are using overall tactics of power and control, through coercion and threats; intimidation; verbal attacks; isolation; minimizing, denying, and blaming; using loved ones; abusing authority; economic control. Lethality risk refers to assessment of a domestic violence survivor’s risk of dying from the current situation. HIGH RISK AND LETHALITY FACTORS: 1. Presence of firearms in the home 2. Strangulation acts 3. Victim’s “gut feeling” of danger 4. Obsessiveness about partner or family 5. Stalking behaviors (especially post-restraining order) 6. Threats (explicit or implicit) or fantasies of homicide or suicide 7. Depression (acute) 8. Separation 9. Access to partner, children or other family members 10. Weapons (threats with, use of, access to) 11. Presence of firearm in home Serious injury or immediate death from strangulation may occur in the following ways: 1. Cardiac arrythmia may be provoked by pressure on the carotid artery nerve ganglion causing cardiac arrest. 2. Pressure obstruction of the carotid arteries prevents blood flow to the brain. 3. Pressure on the jugular vein prevents venous blood return from the brain, gradually backing up blood in the brain, resulting in unconsciousness, depressed respiration, and producing asphyxia (1). Strangulation can also cause brain injury, due to the brain being deprived of oxygen. Some victims can die weeks after being strangled because of the underlying brain damage, even if there is no visible injury (11). Strangulation may cause life-altering consequences, including miscarriage, stroke, and hypoxic brain injury, and could result in death or disability to the patient. These health consequences may occur immediately after the episode or may present days or weeks later after the occurrence (12). The extent of hypoxia and anoxia is relative to the location of compression as well as amount of time the force is applied to the neck and surrounding structures. Hypoxia may inhibit the patient’s ability to recall the strangulation, thus delaying and treatment of the incident (13). Possible health impacts from strangulation include: > Airway obstruction from soft tissue swelling, haematoma. > Injury to the larynx. > Carotid and/or vertebral artery dissection and the potential for significant neurological sequelae at a time in the future. > Anoxic brain injury from arterial obstruction. > Cerebral hypoxaemia due to obstruction of venous return. > Cervical spinal cord injury. > Pregnancy loss/complications. > Mental health issues such as PTSD, anxiety and depression. (Government of Australia, [2023]) Strangulation was more likely to occur during IPV than during SA (sexual assault). This is logical because strangulation is a very personal way to hurt someone: during frontal manual strangulation, the perpetrator is facing the survivor (eye-to-eye) while literally squeezing the very life and breath out of the survivor (14). Differential Diagnosis Non-Fatal Strangulation: Anaphylaxis Angioedema Asthma COPD Depression and Suicide Domestic Violence Epiglottitis Neck Trauma Sexual Assault Spinal Cord injuries (Dunn RJ, et al. Strangulation Injuries. [2023]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459192/) Classic criteria for life-threatening strangulation: Assessing the severity of strangulation or the intensity of an assault is the main forensic task in cases of nonfatal strangulation. Plattner et al. assigned external findings and subjective symptoms to four categories: 1. superficial skin lesions: hyperemia, abrasions and intracutaneous hemorrhage; 2. subjective symptoms indicative of pharyngeal and laryngeal hematomas or swelling: painful palpation, hoarseness and sore throat; 3. distinct petechiae: petechial hemorrhages on conjunctivae, mucosal surfaces and facial skin; 4. subjective symptoms indicative of cerebral hypoxia: for instance, loss of consciousness or loss of urine. Reference: (T. Plattner, et al. Forensic assessment of survived strangulation. Forensic Sci. Int., 153 [2005], pp. 202-207, 10.1016/j.forsciint.2004.09.106) Section 5: Terminology of Strangulation Strangulation is defined as impeding the breathing or circulation of blood flow by applying external pressure to the neck (15). Auto-erotic asphyxia: A case of accidental asphyxia during autoerotic activity. (This is not a suicide or a homicide.) It is the practice of using strangulation to enhance the pleasure of solo-masturbating, but something goes wrong, and death occurs by accidental strangulation. Evidence of a ligature mark is plausibly present. Look for evidence at the scene. The ligature set ups are usually: ropes, chains, blindfolds, and gags. Annually it claims the lives of between 250 and 1,000 young American men (16). In the "choking game" (or "pass-out challenge"), a person purposely cuts off the oxygen supply to his or her brain to induce euphoria. The game is often played in groups, but sometimes it is performed alone, upping the danger. The choking game differs from auto-erotic asphyxia, which is intended to increase sexual arousal. Related Terms (Regarding Strangulation): • Asphyxia: Within the medical forensic context, a condition in which the body does not receive or use an adequate amount of oxygen (Sauvageau & Boghossian, Classification of Asphyxia: The Need for Standardization, Journal of Forensic Sciences. (2010) Vol 55, Issue 5 p. 1259-1267). • Hypoxia: Decreased oxygen to the tissues • Hypoxemia: Decreased oxygen to the blood • Anoxia: Total absence of oxygen to the tissues and organs • Suffocation: A broad, non-specific term encompassing several different types of asphyxia. Although it is often used interchangeably with smothering, its definition is source dependent. Some define suffocation more expansively to include entrapment and environmental suffocation where there is a reduction of oxygen in the atmosphere, as well as choking, where food or a foreign body are obstructing the airway (Sauvageau & Boghossian, 2010). It should be noted that another type of asphyxia, traumatic asphyxia, where external weight is placed on an individual’s chest or abdomen restricting breathing, is often brought under the umbrella of suffocation in IPV cases. Many patients report the experience of an abuser sitting or lying on them during an assault, compromising their ability to breathe. It is appropriate to assess these patients like other patients experiencing suffocation.